In this episode of Psychiatric News Special Report, Dr. Sulman Aziz Mirza speaks with Dr. Sarah El Halabi and Dr. Stephen J. Ferrando about why lithium remains underused despite its established role in treating bipolar disorder. They explore how specialized lithium clinics and standardized monitoring can support safer prescribing for pregnant and postpartum patients, older adults, and people with renal disease. The conversation also addresses misconceptions about lithium toxicity, the challenges of managing complex medications, and the importance of coordinated, team-based care.

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Transcript

Dr. Sulman Aziz Mirza (00:00) The future of psychiatry depends on members who are willing to lead. APA's call for nominations is now open and we invite you to nominate yourself or a colleague for leadership and volunteer opportunities. Help shape the future of our profession. Visit psychiatry.org slash elections. Nominations close September 1st.

Dr. Sarah El Halabi (00:05) is Visit.

Dr. Sulman Aziz Mirza (00:32) Welcome back everybody to the July episode of the psychiatric news special report podcast. We have wonderful article today, lithium clinics and high risk populations with bipolar disorder. We are joined by two of the authors. We have Dr. Sarah El Halabi and Dr. Steven Ferrando here with us. I'll let you them both introduce themselves, a little bit of their bio, their background and their blah, blah, blah.

Dr. Stephen J. Ferrando (00:59) Sarah, go ahead. Yeah.

Dr. Sarah El Halabi (01:01) Hey everyone, thank you for having me. I did my residency at Westchester Medical Center and then I did my fellowship in CL and Women's Mental Health at Yale. And I am starting a job in the Cleveland Clinic where I'll be doing both CL and Women's Mental Health. And so those are my clinical interests. Outside of that, I immersed in the narrative medicine world and the literary world in general where it brings me a lot of joy. Happy to be here.

Dr. Stephen J. Ferrando (01:28) Hey everyone, I'm Dr. Steve Verando. I'm the chair of psychiatry at Westchester Medical Center Health Network and New York Medical College. I had the pleasure of having Sarah as one of our outstanding residents who also chose a pathway that I've chosen throughout my life as a consult liaison psychiatrist. That's my central identity. And I think in terms of the article we're gonna discuss, we love to embrace complexity. And certainly that's what's at hand here in prescribing lithium in potentially high risk populations.

Dr. Sulman Aziz Mirza (02:17) Yeah, I don't know. There's something about the CL psychiatry group with the world where they end up in leadership positions because they know what's going on in the hospital systems, right? They have to interact with all of them. So this is a little something. So I primarily do like a child and adolescent work. So we don't get to play around with lithium as much, but I thought this was an interesting article for many, many reasons. So this... Article is, know, lithium is a first word in the article, but it's not necessarily about like lithium so much. it's more about the complexities that come along with lithium. And then some of the other psychiatric meds, think we'll talk about it in a little bit about that make them unique and a little bit of a challenge and how sometimes as much as like lithium is this very unique psychiatric to psychiatry medication. It's kind of falling out of favor and we're not using it nearly as much as we have in the past. And, you know, think part of the article says that there are residents coming out of training who hardly have ever prescribed it or if at all. it's like, it's kind of a shame, especially for a medication that is so, so, so well established and so unique to the field itself. So Dr. Halabi, do you want to talk about that or a little bit?

Dr. Sarah El Halabi (03:42) Yeah, sure. I'm happy to answer that question. So part of how this idea popped in my mind was that I was seeing different patients, some of them were pregnant, but a lot of them were older people on lithium who would come in with all these problems. And I kept thinking, why is that the case? And I casually just asked my co fellows and people around me like, hey, like how common is lithium prescribed? And the answer was not that common. So I thought, why don't we just centralize the prescription of lithium? Because it's seeming to me that it's not as popular as it used to be, especially as the older psychiatrists would just say, yeah, lithium, we're very familiar with that. And that's sort of how this idea was born. I don't think it's a particularly unique idea because lithium, as you said, is a well-established medication, but the idea of putting it in one place and controlling all the variables might be.

Dr. Sulman Aziz Mirza (04:34) Yeah, Dr. Friend, do anything to add to that as maybe someone who's a little more seasoned per se.

Dr. Stephen J. Ferrando (04:40) Sure, mean, yeah, there's a lot of elements to this. I mean, I think, you know, on a system level, you know, when you have acute care patients, we're often thinking about using lithium because patients tend to be more treatment refractory. You tend to see more acute manic episodes or refractory depression where you're looking to do augmentation. So we are more inclined in that setting to think about initiating lithium, although it may not be the first choice often like in acute mania, where frankly, I think that the marketing of a lot of the atypical antipsychotics and the perceived ease of use and lack of need for serum level monitoring and toxicity monitoring appear to be less. And so I think there's a certain comfort level with that newer generation of medications, many of which do have indications for, you know, acute mania and even prevention of relapse. But, you know, we know lithium has some unique properties in including, you know, other areas of medicine recognize even some neuro regenerative properties of lithium. So You know, I think on a system level, then it's important to set up structures that can help facilitate psychiatrists have to have a comfort level in monitoring these meds and monitoring the potential for toxicities, both short and long term. think that's really what we were kind of seeking to write about is not only that lithium works and it has a lot of uniqueness, but How do you set up systems that create a comfort level for the prescribers to really use this medicine?

Dr. Sulman Aziz Mirza (06:47) We were talking a little bit before everybody kind of joined on Dr. Halabi and myself about we had just had a journal club meeting where I work at Inova Healthcare over here in Northern Virginia. And it was about clozapine. A very similar kind of discussion was brought up about, you know, a resident was kind of leading the journal club about clozapine and how, you know, I never prescribed it during my whole training and what is this medication and kind of the fallout of the the REMS changing, the REMS change or the elimination of the REMS, we should say with clozapine in the past year and what's happened with that. And I had just gotten this article in my email, I think earlier in that day or a couple of days ago when I'd read through it and I was like, oh, this seems like a very apt kind of parallel of lithium clozapine, these two again, classically psychiatry medications that have fallen out of favor because I think Dr. Fonda, what you were kind of saying, It's hard to prescribe them. There's a of challenges that come along with them. And for a lot of psychiatrists who may be not in a hospital setting, not in an outpatient setting, there's a lot of work and there's, I don't want to say laziness, but additional hoops that have to kind of go along with prescribing any of those medications, correct?

Dr. Sarah El Halabi (08:04) Yeah.

Dr. Stephen J. Ferrando (08:04) Yeah. And I, I do also work some, time in a community clinic where I'm more isolated and doing med management and it is, it's a heavier lift. So we will get patients who are prescribed these higher level monitoring meds like lithium and clozapine and long acting injectables, right? And, and, the patients will come and we're much less equipped. you know, kind of you have to see the patients one by one. So you have to set up a process whereby, you know, you're creating the same standard for every patient and making sure that things don't fall through the cracks. And that is definitely a challenge. So I think the idea of having sort of a, you know, a special day or a special clinic or, you know, wherein you leverage all the, you know, the people who are have the expertise and you have a standardized monitoring protocol so that you're thinking about everything for every patient in the same way, right? It makes it easier.

Dr. Sarah El Halabi (09:18) Yeah, I also do kind of want to add to that, that SMI is a big, is a heavy load. It's not something that people manage alone. takes a village. And there is definitely the convenience, whether you're in a psychiatric hospital or a medical one, that there's a team every day, you're there, they're there, they can get a level, everyone's talking to each other versus being one person in a clinic doing all this alone, you're going to have challenges.

Dr. Sulman Aziz Mirza (09:46) So who are the people, let's talk about that, guess, who are the people that are making up this village? Who's in these lithium clinics that are proposing?

Dr. Sarah El Halabi (09:55) I think the thought was it depends on the group we're talking about. For example, like in older people, Maybe geriatricians, nephrologists, internists. For pregnant women, it would be different. I think it depends on the high-risk population that has the bipolar disorder. And the psychiatrist obviously embedded in each of these.

Dr. Stephen J. Ferrando (10:20) Yeah, and it may be difficult, obviously, from a structural standpoint to have all those people in the same room at the same time, right? So you can leverage other things like you might, for instance, we're setting up here at the medical center, a what we call an advanced psychopharmacology clinic, which subsumes, you know, lithium, clozoril, LAIs. and refractory polypharmacy, refractory patients where polypharmacy is employed and it serves both kind of a consultative functioning and then a monitoring, prescription and monitoring function so that you're applying the same idea to multiple complex drugs. But that's in a health system like this where you know, we're kind of setting it up so that, yeah, these are complex patients. You come here for this, if it's not viable on a solo outpatient basis to be following, you know, this type of patient. And so then we can bring to bear other specialists either by telehealth or other type of consultation to kind of have one EMR. Right? Because that's important too, because multiple specialists may be involved if you're worried about renal complications, chronic renal complications in a patient on lithium. But you want to keep them on that medication because it's working for them, right, for many years. Then, you know, you need to kind of have all the expertise in one place and be able to access the information in the labs and all of that. I think that's very critical.

Dr. Sulman Aziz Mirza (12:14) Yeah, I think that's something, you know, again, we talk about healthcare systems as a lot and how everybody's talking their own language, is in a way as if everyone's on different EMRs, it doesn't work, right, especially if we're looking at a team kind of setting and having that village per se that we had discussed before. So talk to us about, I think, Dr. Alavi, there are three main groups, three main populations that would be best served. the older generations, people who are geriatric patients, pregnant individuals. And then there was one other group, the other group was the renal disease. Yeah. So go through, guess, if you guys want to tag team, going through these populations about what are some unique challenges and how can we help them out more.

Dr. Stephen J. Ferrando (12:55) Yes.

Dr. Sarah El Halabi (13:08) I can start by speaking about pregnant folks. some of the challenges that pregnant people face is, well, a, general, how does my illness affect the baby, but also how does the medication affect the baby? And you can see this with a wide range of medications and lithium is not an exception. Unfortunately, in bipolar disorder, the postpartum period is a very high risk period. And so we want people to be stable ASAP. And lithium is a big gun. So having that explained to people and having the ideas about lithium being a dangerous drug debunked is very useful because you guarantee the stability of both mom and baby. And I can definitely say that in the MFM clinic I was in that discussion was had many times successfully. So it is possible.

Dr. Sulman Aziz Mirza (13:57) Yeah, kind of like before going switching off to here, talk, talk to us about those, you know, just for people who may not remember from like step one and step two, like some of the risks like Epstein's anomaly and everything else that comes along with and how are they overstated almost to

Dr. Sarah El Halabi (14:15) I think the issue, and if anyone here knows more, please correct me, of abstinence anomaly is that it is a relative risk and not an absolute risk per se. it's, it's always compared to what is the existing baseline. And given the risk of uncontrolled bipolar disorder and the relative risk of abstinence anomaly, uncontrolled disorder, of bipolar disorder, of trumps. There are some risks with lithium that people need to be aware of, like thyroid issues, renal issues in mom. And we always recommend for the baby to get care by the pediatrician and for the pediatrician to know that the patient is on lithium. And for mom as well, there are some labs that need to be done because as mom goes into the third trimester and then delivers, lithium is a very water dependent molecule, if you want to say that. And so we need to be very aware of the serum levels of lithium and her increasing need of lithium in the third trimester, then to decrease that. when she delivers. So it needs a lot of monitoring, but it's very possible.

Dr. Stephen J. Ferrando (15:20) I would just compliment with what Sarah said in that she's absolutely right. When you have medical complexity and pregnancy certainly has this multi-level consideration here with the mother and the fetus, but it's always important to look at the benefit risk calculation. in light of the fact that something like Epstein's anomaly is, as she said, a relative risk, but an extremely low absolute risk, right? whereas we know that complications of untreated bipolar disorder in the mother can greatly affect the developing fetus and childbirth, you know, et cetera. it's it's extremely important to be aware of that and not to be either, you know, I mean, and you have to sort of manage your response to that, right? Because you can't be, you can't overshoot and not prescribe it at all, but you can't be willy-nilly either, right? So, and that's where it gets back to this having a system of monitoring and having a high-risk OB involved and having open communication and things like that so that you can stipulate, hey, this is necessary and we need this type of situation to monitor.

Dr. Sulman Aziz Mirza (16:58) Yeah, I think we all have lost count. I think of the number of patients who are, been pregnant, been told by their OB or somebody else, they're like, Hey, you can't be on this medication. You need to get off of it. And then they just stop it cold turkey. And then you have those relapses and in the mania, et cetera, and causes problems to mom and baby, right? It's like that there's so many times that this occurs and it's one of like, again, the greatest I don't want say myth, it's like, you know, there's the nuance that's necessary when we're having these discussions that like there's ways to treat it without kind of necessarily going fully, fully off of it or staying fully, fully on it. And that's important. I just want to hammer that home to everybody. So who wants to talk about, let's say maybe the renal disease folks, this other population.

Dr. Stephen J. Ferrando (17:50) Yeah, I mean, I can I can feel that a bit. So there's a couple of different levels to this is, you know, one of them is this concern about the development of chronic renal disease and renal failure in patients who have been on long term lithium. Right. So I mean, that's an important distinction because patients can over time develop renal insufficiency as measured by BUN creatinine, creatinine clearance, et cetera. But the actual risk of precipitating renal failure and going to dialysis is very, very low. And some of that is related to our vigilance about how to prescribe these meds, right? We generally do a pretty good job so that the, you know, the over time, the absolute risk of inducing, you know, chronic renal failure and maybe even needing dialysis and transplant is extremely low, right? So we've kind of addressed that. But there is a very, you know, there's a small and measured inherent risk. Right? So that's the one side of does lithium cause renal insufficiency, renal failure? Yes, to a degree, but not as catastrophically as we might be concerned about. Right? So then there's the other side of it is in patients who actually have renal failure or renal insufficiency, even patients on dialysis. First of all, I should mention that renal... that lithium is dialyzable in overdose, right? So that's one of the big advantages of being able to have lithium as a renally excreted molecule and so forth that we can, you know, if a patient unfortunately overdoses, we can dialyze that patient. So that's great. But for the... actual dialysis population, there are some patients who are on, you know, lithium. Often they're on lower doses because of the clearance issues. But remember, when that patient goes to dialysis, that lithium is going to be cleared, right? So you're removing that lithium from them every time you dialyze. So those patients are then often dosed after their dialysis session. So if they're Monday, Wednesday, Friday, or whatever, you on those days you just dose the lithium after their dialysis.

Dr. Sulman Aziz Mirza (20:48) I think it goes to like one of those myths, right? Again, they're like, if I'm having a discussion outpatient and I'll bring it up, they'll be like, well, isn't that gonna destroy my kidneys? Am I gonna end up on dialysis from this? And it's like, I think we were saying in the article about like a 1 % chance, up to like a 1 % chance of of lithium induced renal failure, correct? Something along those lines, so.

Dr. Stephen J. Ferrando (21:15) depends on, right, it depends on where you see, but yes, it's relatively low now. And we all counsel our patients about hydration. And, you know, I try to make my patients a little bit, you know, like really focused on that kind of thing, especially in the type of weather we have now. You know, look, you need to stay hydrated. We all do, but especially, you know, and so the patients tend to pick up on that, you know.

Dr. Sulman Aziz Mirza (21:43) The last population is, know, one of the main reasons I do focus more on child adolescent work is the older population, right? They end up on all these meds and all these, you know, medical complications that, you know, from my brain is a little bit more than I'm like wanting to work with and figure out. But talk to us a little about some of the unique challenges in older adults with lithium.

Dr. Sarah El Halabi (22:08) We can probably tag team this one. As you said, polypharmacy is a problem, and especially if part of that polypharmacy is diuretics and NSAIDs. And I do believe I remember a case where that patient was on two different diuretics and lithium, and the diuretics were prescribed by different people. So that's a problem. And older adults often end up on a lot of medications, so there has to be a system of monitoring that keeps them together. Their physiology is also vastly different than, well maybe not vastly, but quite different from younger people with the changes leading to higher lithium levels or normal lithium levels giving them more side effects. So these are things that have to be watched.

Dr. Stephen J. Ferrando (22:56) Yeah, and I think it comes to mind a patient that I'm actually treating. on the inpatient service right now treating a patient who's 67, long-term bipolar disorder admitted in the setting of a manic episode with treatment nonadherence. And lithium works for this individual who happens to also be diabetic and to have a bit of a creeping creatinine. So the patient is very aware that the lithium works for them, but you've got the diabetes, you've got the creeping creatinine, you've got the fact that he happens to be hypertensive and needing to manage the diabetes and the antihypertensive. And patient wants to be on lithium. So we start them, you know, at a lower dose and elevated gradually. And, you know, he's doing well, but this is the type of patient who's older, had accumulating complications of their underlying physical illnesses, responds well to lithium, wants to be on lithium. You really just need to set up. and he's, by the way, a hypothyroid. So we had to adjust his high thyroid medication. you know, all of these elements that are cumulative over time, but his psychiatric illness is devastating and it needs to be treated. So you just have to have that system of care that can take care of him.

Dr. Sulman Aziz Mirza (24:44) One of the questions Dr. Frendel you had mentioned before was the systems question and in regards to with psychiatry, think from a hospital point of view is not always seen as like the great big moneymaker, right? And it's the resources that go towards it is not from our point of view enough, right? It's never enough, right? And something like a lithium clinic, a clozapine clinic, anything along those lines, psychopharmacology clinic, like you were saying, I think is another ask of the system, right? How do we... How do we justify this? How do we kind of talk about this and say, or pitch this in a way? How can we all pitch this to get this going for other systems?

Dr. Stephen J. Ferrando (25:34) Yeah, mean, we in CL psychiatry are very used to talking about indirect benefits, right? There's always a need for a consult psychiatrist in the MedSurg hospital, but there's never the funds and, you know, who's going to pay for it. But I think that there is direct and a lot of indirect benefit. to having this type of program in a hospital system because inevitably we get these complicated patients like the population is aging. If you embrace maternal fetal medicine, you're dealing with maternal mental health. You are dealing with these specialized populations who cannot be sufficiently cared for in the normal system where it's potentially fractionated, right? So if you approach this with intention, you solve the problem of the system and also the providers who are trying to take care of these, the doctors generally who are trying to take care of these patients. And in addition to that system level, benefit, this can be a referral source for doctors, prescribers in the community who are struggling with a certain type of patient who has more complex psychopharmacology needs. And I think that's what we're trying to emphasize, that this is sort of a consultative program. It also feeds into things like interventional psychiatry interventions, Like esketamine, ketamine, neuromodulation therapies, so that they can all kind of complement each other. And I think that's the approach we're trying to establish and kind of become that go-to referral source for those complicated patients where maybe the folks in the community need a little extra help.

Dr. Sulman Aziz Mirza (27:57) Do you feel like with lithium that we're romanticizing it a little bit too much? That we've kind of, know, maybe we're, you know, I was saying before in the beginning, we've fallen out of love with lithium, but are we kind of being a bit looking at through rosy tinted glasses? do we, with that we need to bring it back.

Dr. Stephen J. Ferrando (28:21) Sarah, you wanna comment?

Dr. Sarah El Halabi (28:23) Yeah, I actually tried to have this same discussion with some older psychiatrists and some of them were of the opinion that we are romanticizing lithium, that it does have a lot of side effects. I don't have a tangible answer to your question, but I do think that it will benefit those who it needs to benefit and shine completely away from it, which is what I feel we're at now, is not super helpful. So perhaps the golden mean.

Dr. Sulman Aziz Mirza (28:49) Yeah, it's something I think we're struggling with because I think we see this, you know, the outpatient real life basis is that, you know, we're being pushed towards, you know, the antipsychotics, the second generations, they're just quote unquote easier to use, less kind of hassle per se. And then, you know, sometimes we have a patient who ends up on lithium, whether it's through hospitalization or through something else. And it's like, where has this been my whole life? You know, this is the thing that's helped them the most. it's like, well, it's. been around for hundreds of years, but you know, we've kind of stopped using it for whatever reason that's there.

Dr. Stephen J. Ferrando (29:27) Yeah, think it's one thing I would say is that, I don't know, it's always it's kind of human nature to make old things new again. And but I think that there really is a role. There's clearly a unique role for lithium. And it may not be the first line. Right. Unless it's a certain category of patient who's hospitalized with mania, for instance. I mean, I think it's very legitimate to offer lithium as a first line to that patient, being mindful of all the monitoring needs and the potential long-term side effects. But yeah, I mean, think net-net, it's probably still underutilized, and probably fewer people are thinking about it than ought.

Dr. Sulman Aziz Mirza (30:23) gonna be mindful of all of our times, but any kind of closing recommendations or thoughts, Dr. Halabi or Dr. Ferrando?

Dr. Sarah El Halabi (30:33) Just the simple notion that wherever there is a problem, is a solution.

Dr. Stephen J. Ferrando (30:38) Well said.

Dr. Sulman Aziz Mirza (30:39) All right, and then last kind of question before everybody gets on their way, but I was asked about everybody's kind of self care because we all need our own self care. So what do you all do for your own self care during these times?

Dr. Sarah El Halabi (30:54) I'm a big meditator. I meditate and I bake a lot.

Dr. Stephen J. Ferrando (30:58) Yeah, I'm a I'll say avid if not obsessive runner So I I've been running for many many years. It's my meditation and my exercise and my self-care

Dr. Sulman Aziz Mirza (31:13) Awesome. All right, everybody. Well, thank you both. Thank you both for your time. in this article, again, lithium clinics and high risk populations with bipolar disorder. This is in the July edition of psychiatric news, special report. you can find that online psychiatry online.org. and also remember to leak, you know, give us a like five star rating for the podcast, wherever you're listening to subscribe and share with everybody. then. We will see you in the next month then. Thank you so much for your time.